December 2000 Bulletin


‘. . . I do try to sit down and listen to what they’re telling me. . . .’

Orthopaedists tell keys to success in patient relations

By Carolyn Rogers

While the public at large may view orthopaedic surgeons as "high tech" but not "high touch"—as a recent AAOS study suggested—many glaring exceptions to that stereotype exist. A number of orthopaedic surgeons across the country are proving themselves to be not only technically adept, but compassionate, connected physicians who know how to make their patients feel "heard" and valued. And in return, their patients offer their trust, refer their friends, neighbors and co-workers, and when asked about "patient satisfaction," eagerly award their doctors with the highest marks.

A few of those orthopaedic "success stories" have been singled out by a patient office performance survey administered by Elizabeth Stringer, a registered nurse. In 1996, Stringer began conducting patient satisfaction surveys in orthopaedic offices, and others when she was asked by some orthopaedic surgeons to develop a survey that was statistically valid.

"I did an extensive literature search," Stringer says, "and couldn’t find a survey that had gone through the statistical process to make sure the questions you’re asking are the ones the patients are answering—that you’re using the right words. Once I developed the patient office performance survey (POPS), it really took off."

Patient satisfaction surveys and improved patient-physician communication, have taken on a new importance in the increasingly consumer-driven health care market. No matter how technically skilled, doctors who don’t "rate" with their patients don’t make the cut with insurance plans. And many argue that better communication between doctors and patients leads not only to higher patient satisfaction, but better health outcomes.

All of the 190 physicians in Stringer’s database are voluntary participants. More than 91 percent of Stringer’s current database of 30,000 patient entries comes from orthopaedic patients, the rest from other specialties. The reasons cited by doctors for participating in the survey are varied.

"Sometimes the office manager knows there’s a problem and wants to put a number to it, " she says. "Other doctors do it to look good to insurance companies, and some just want to know how they are perceived by their patients and how they might improve. And of course, they’re curious how they compare to the orthopaedist down the street or across the country."

Stringer supplies each doctor’s office with a one-page form with 22 questions, to be handed out at the end of a visit. Patients fill out the anonymous form at home and mail it to an office in Denver were the data is input. After the results are tabulated, Stringer lets the practice know in which areas the office is succeeding, as well as the areas with "opportunities for improvement."

"Once they have these numbers, though, the doctors may wonder, ‘Is 91 a good score for my nurse or business department?’ Because it’s statistically validated, I am able to compare different physicians with each other. When they get the comparisons, it’s often a wake-up call. Most of the physicians think they’re doing a good job—it’s kind of like being a parent. And they’re very sensitive about getting report cards…They’re a pretty competitive group, and nobody wants to be at the bottom of the heap."

Of course, Stringer points out, physicians score differently according to their subspecialty and patient population.

"Orthopaedists who see a high amount of work compensation and chronic pain, such as hand specialists, tend to rate lower," she says. "And some surgeons with a more diverse patient population will rate lower than surgeons who specialize in total joints on patients over 65. Older patients tend to rate their doctors high—that’s just the nature of the beast. You’ve got to be comparing apples to apples."

General orthopaedists tend to rate higher than subspecialists, Stringer says, partly because they really need their patients to talk in order to make a diagnosis.

"If someone goes to a general orthopaedist and says ‘my leg hurts,’ the doctor needs to ask questions. Whereas, if I go in for a total knee replacement, the doctor really doesn’t need to ask me very much. And while that may be the case, from the patient’s point of view he hasn’t been ‘heard.’"

Another factor she looks at is the size of the group. "Groups that have over six doctors have a harder time keeping patient satisfaction high—it’s more of a system, less personal."

Surprisingly, the volume of patients an orthopaedist sees doesn’t seem to affect the ratings. "You might think that new docs who see three patients an hour can make them [the patients] happier," she says, "but that’s not true."

So who’s at the "top of the class" in Stringer’s database?

Nonorthopaedists grabbed the top 20 spots—mostly internists and family physicians, but "that’s to be expected" Stringer says. However, a general orthopaedic surgeon, John Tongue, MD, of Tualatin, Oregon, managed to secure the 21st spot, while three other orthopaedists follow closely behind—Gary Hess, MD, of Denver, Colo.; William Mangione, MD, also of Denver; and Dennis Phelps, MD, of Colorado Springs, Colo.

"I really think patient satisfaction surveys will drive the interest in communication," says Dr. Tongue. "I’m very hopeful that the Academy will endorse a patient satisfaction survey that we can all use and learn from. We are all by nature pretty competitive and want to believe we’re doing a good job, and these surveys give us a baseline for where we stand in a consumer health care driven market."

The point of the surveys, though, "is not just to identify people, but to give them a chance to improve their communication skills and satisfaction rates because that satisfaction will lead to better outcomes, " Dr. Tongue adds.

Dr. Tongue partly attributes his high scores to being a "community-based orthopaedic surgeon." He says he’s tried to earn his patients trust by staying in one place for 23 years.

"It’s a lot more fun to practice when patients listen to what you say, and value it; when they come to you on a consensual basis, rather than a contractual one. I have a solo practice, and one of the advantages that’s often overlooked, is that in the era of managed care, patients appreciate the personal treatment they receive in a boutique-type of office. In a larger office, they receive less personal attention and may see different people on different visits. Their satisfaction is going to be less."

In a typical patient interview, Dr. Tongue says he tries to ask appropriate open-ended questions to give the patient a chance to tell his or her story. And he tries to express his feelings for the patient and their condition.

"If for some reason I feel I’m still not connecting, I take extra time to see if I’ve overlooked something," he says. "Maybe their work situation or the way their treatment is affecting their spouse is more important to them than anything else right now, and I just haven’t found that out yet….And of course I try to get them to buy into the treatment program. I ask questions to make sure they really believe that what I’ve suggested can help them. Because if they don’t believe it, they’re never going to follow through."

For those busy doctors who believe they don’t have time to put these skills into practice, Dr. Tongue points out an interesting survey result.

"According to this survey, the average time I spent with my patents was 15 minutes, while the average time for an orthopaedic surgeon was 20 minutes. So that addresses another concern that physicians have in hearing about this topic—that they wouldn’t have the time to practice these more ideal communication skills. If you improve your skills, you can actually get the information and educate your patients in the same amount of time, or in some cases less, and they’ll have high satisfaction."

If you’d like to hear more of Dr. Tongue’s ideas on this topic, he’ll be moderating two instructional course lectures on patient physician communication skills at the Annual Meeting in San Francisco on March 1.

Ranking just a few hundredths of a percentage point behind Dr. Tongue is William Mangione, MD, a general orthopaedist in Denver.

"The survey actually showed that we were doing better than I thought," Dr. Mangione admits. "Not just me personally, but also our staff. It was a pleasant surprise to see our front staff so highly rated."

In retrospect, Dr. Mangione attributes his personal high scores to taking time with his patients.

"I do try to sit down and listen to what they’re telling me, and I make a conscious effort not to leave the room until their questions are answered. I don’t like to leave them with a puzzled expression on their face."

If a patient has a complex problem—with several alternative courses of action—he goes through his thought process with them. "I think out loud, and I believe the patient appreciates that and it gives them the understanding that this is not a straightforward problem."

The only major change Dr. Mangione recalls making in his interactions with patients was when he was just a year or two into his practice.

"I tend to see things from a humorous angle and I tried to impart that in the way I dealt with everyone," he says. "That didn’t go over too well with all my patients—they may have taken it as a little flip, and I got that sense after a while. So I changed that fairly quickly. Now I show them I’m taking things quite seriously unless they show that they’d like to take a more humorous slant on things."

In general, Dr. Mangione says "we impart to our staff, by example, the fact that we take everyone’s problems seriously and treat the patients courteously. We also made a pretty conscious effort not to cram too many patients in at a time. It annoys me if I go to a doctor—or anywhere—and they are overscheduled. So we kept the number of patients in a day to a manageable number."

At the time of the survey, two years ago, Dr. Mangione’s patient population was "very much a cross-section," he says, "everywhere from kids to elderly, from sports medicine to reconstructive surgery." He is now employed by Kaiser Permanente, which also routinely administers patient satisfaction surveys, and has an older patient population. While continuing to score quite well, Dr. Mangione concedes his scores now "might be a tad lower. We have less control over how long patients wait for an appointment to see us, and no matter how nice we are, if they’re mad when they see you, there’s not much you can do."

A third patient-physician communication ‘success story’ belongs to general orthopaedic surgeon Dennis Phelps, MD, whose group practice includes the "whole gamut" of orthopaedic problems and age groups.

Dr. Phelps’s philosophy is to get to know the patient as a whole rather just their specific orthopaedic complaint. He says "it may take you a couple extra minutes with each patient during the first visit, but on subsequent visits you kind of expound on the knowledge you’ve gained before, so it doesn’t take any more time at that point."

Dr. Phelps credits some of his communication skills to his training in internal medicine prior to entering orthopaedics, and says he was fortunate to have many instructors and mentors over the years that served as role models in this area.

His office’s survey results surprised Dr. Phelps in one way. "Despite my perception if the office running smoothly and efficiently," he says, "our patients were actually waiting a little too long out in the waiting room. So since then, we as a group have rededicated ourselves to trying to move patients more efficiently."

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